Knowledge and attitudes about vitamin A consumption and its relationship with night blindness in university students

Introduction Night blindness is the first sign of vitamin A deficiency (VAD), which can lead to blindness if left untreated. University students may be at risk of VAD-related night blindness due to unhealthy eating attitudes and inadequate vitamin A intake. This study aimed to determine the relationship between knowledge and attitudes toward vitamin A consumption affecting night blindness in university students. Methods This cross-sectional study involved 409 third-year university students of Universitas Islam Sultan Agung, Semarang, Indonesia. Participants completed questionnaires about socio-demographics, their knowledge of vitamin A, and attitudes toward vitamin A consumption. Night blindness symptoms among university students were assessed using the Low Luminance Questionnaire (LLQ), followed by a bivariate analysis of the Chi-Square test. Multivariate binary logistic regressions were used to determine whether the independent variables were associated with night blindness. A p-value less than 0.05 indicated significance. Results The prevalence of high-symptom night blindness was higher among males (26.4%) than females (5.7%). Out of 409 university students, 48 from the non-medicine cluster of the study program had a night blindness symptom. The prevalence was lower in students who studied in the medicine cluster program. The level of knowledge on vitamin A had a significant relationship with symptoms of night blindness [prevalence ratio (PR) = 2.239 (95% CI = 1.110–4.516)]. The attitudes toward vitamin A consumption were significantly associated with night blindness (PR = 2.560, 95% CI = 1.215–5.392). Discussion The results of this study show that the risk of night blindness in university students can be prevented by increasing their knowledge and attitudes toward consuming vitamin A-rich food. The university can provide health promotion and vitamin A supplementation to avoid night blindness among academia.


Introduction
Vitamin A is an essential nutrient that is crucial in maintaining eye health.Vitamin A's active all-trans retinol metabolite endures a cycle that generates rhodopsin for light perception in the eye (1).Rhodopsin is involved in the dark adaptation process, allowing humans to see in the faint light.People with night blindness can see well during the day due to their cone 10.3389/fmed.2024.1309837Frontiers in Medicine 02 frontiersin.orgcells, but they have difficulty seeing at night due to the ineffectiveness of their rod cells.Vitamin A deficiency (VAD) causes night blindness, resulting in the challenges of performing tasks in faint light or at night (1,2).Night blindness is the first symptom of VAD, which can lead to blindness if left untreated (3)(4)(5).Consuming foods deficient in vitamin A is common in developing countries (6,7) due to poor eating habits.University students tend to consume high-calorie food selections, fast food snacks, fried food, and a low intake of daily fruits and vegetables (8).The low intake of vitamin A-rich foods among university students can increase the risk of ocular health disorders (9-13), especially night blindness.
Previous studies focus on vitamin A, and conclusive findings indicate that many university students suffer from vitamin A deficiency.The average daily intake of vitamin A among university students was about 2,500-5,000 IU.The treatments of 3 capsules containing 100,000 IU improved in dark adaptation, as indicated by the decrease of the final rod threshold of more than 0.15 log μμl (14).A recent study by Wan et al. reported no vitamin A deficiency in college students; however, all the students are vitamin E deficient (15).Knowledge, attitudes, and practices of medical students regarding vitamin consumption have been studied in China (16,17), but we did not find vitamin A deficiency in medical students in Indonesia and its effects on night blindness symptoms.
Preventing VAD in university students, especially medical students, is vital in reducing errors in identifying color slides and specimens and investigating specific physical signs (18).The serial monitoring of electroretinogram (ERG) testing showed that vitamin A supplementation could restore VAD-associated night blindness in patients with nyctalopia complaints (19).Therefore, precautionary measures can be taken to improve knowledge and attitudes toward consuming vitamin A (20).This study aims to determine the relationship between the level of knowledge and attitudes toward vitamin A-rich foods consumption and night blindness symptoms in university students.

Study design, population, and sample
This research is an analytical observational study with a crosssectional design.Nine faculties at the Universitas Islam Sultan Agung, Semarang, Indonesia, involved in this study, categorized into 2 clusters.The study program of the Medicine cluster consisted of students enrolled in the Faculty of Medicine, Faculty of Dentistry, and Faculty of Nursing.In contrast, the non-medicine cluster included the Faculty of Law, Faculty of Islamic Studies, Faculty of Languages and Communication Sciences, Faculty of Engineering, and Faculty of Industry Engineering.The inclusion criteria were university students in 3rd-year bachelor study, while the exclusion criteria were missing written consent and night blindness before university.The sample size was 368, calculated using the following equation (21); where n is the minimum sample size required in the study, Z is the area under the curve corresponding to the desired confidence interval used in this study, i.e., 95% CI (1.96), P is the prevalence of vitamin A deficiency (VAD) in Indonesia (60%) (22), and d is the precision [difference between sample mean and population mean (+/− 5%)].Assuming adding 10% of the sample size, 409 university students with bachelor's degrees were involved in this study.

Data collection tool and measurement
The data collection was performed on 1-31 July 2022.All research instruments, including the consent forms and questionnaires, were available in Indonesian.The questionnaires were arranged in a Google form and shared through a WhatsApp group of students.The students filled out the questionnaire, and we provided online guidance when necessary.
The self-administered structured questionnaire consisted of sociodemographic characteristics (gender, age, and faculty), vitamin A knowledge, and attitudes toward vitamin A consumption (23).A knowledge-level questionnaire on vitamin A consumption consists of 20 questions about vitamin A deficiency's sources, benefits, and consequences (Table 1) with the response of True or False.The level of knowledge is categorized as low-middle if the number of correct answers is 0-13 and high if the right answers are 14-20.Vitamin A consumption attitudes were asked through a questionnaire with 20 questions (Yes or No responses) related to the type, frequency, and habits of consuming foods that contain vitamin A (Table 2).Attitudes are categorized as low-middle (0-13 correct answers) and high (14-20 correct answers).Before conducting the research, the self-designed questionnaire was administered to 50 randomly selected university students for comprehension testing to ensure validity and reliability.The validity test showed that the corrected item-total correlation was >0.279, while the reliability test showed that Cronbach's Alpha values of all items were > 0,279.Therefore, no significant changes were made due to the preliminary examination.
Symptoms of night blindness were assessed by the Low Luminance Questionnaire (LLQ).This LLQ is a valid and reliable test for patientcentered assessment of visual function in a low luminance or mesopic setting (24,25).The questionnaire was initially accessed in English and modified into Bahasa Indonesia (the national language).The LLQ is a 32-item questionnaire with six subscales related to low luminance settings: driving, mobility, extreme lighting, general dim lighting, and peripheral vision (Table 3).Each question can be answered with Yes or No. Symptoms are categorized as low-middle if the number of "Yes" answers is 0-21 and high for 22-32.

Data analysis
Data were analyzed using IBM SPSS Statistics version 25.0 for Windows.A bivariate analysis of the chi-square test was carried out to explore the relationship between knowledge and attitudes toward vitamin A consumption with the appearance of symptoms of night blindness.Multivariate analysis of logistic regression was used to determine the most influential variables on the signs of night blindness.

Results
Table 4 shows the sociodemographic data of the participants.A total of 409 university students participated in this study, of which 47.2% were female and 52.8% were female.A total of 56% respondents studied at the Medicine Cluster Study Programme (Medicine, Dentistry, and Nursing), while 44% were enrolled in the Non-Medicine Cluster (Islamic Studies, Law, Language and Communication Sciences, Economics, Electrical Engineering, and Industrial Engineering).
The prevalence of high symptoms of night blindness was higher among males (26.4%) than females (5.7%).The prevalence of night blindness did not differ significantly between the two age groups (p > 0.05).Out of 180 university students from the non-medicine cluster of the study program, 48 (26.7%) students had a night blindness symptom.The prevalence was lower in students who studied in the medicine cluster of the study program (8.7% out of 229 students) (Table 5).The level of knowledge on vitamin A had a significant relationship to the symptoms of night blindness with a prevalence ratio (PR) of 2.239 (95% CI = 1.110-4.516).However, it can be seen that 19% out of 295 students with a high level of knowledge about vitamin A showed a symptom of night blindness.The attitudes toward vitamin A consumption were significantly associated with night blindness (PR = 2.560, 95% CI = 1.215-5.392).However, 21.2% of the 273 students with high attitudes toward vitamin A consumption showed high symptoms of night blindness.

Discussion
This cross-sectional study aimed to determine the association between knowledge and attitudes on vitamin A consumption and night blindness symptoms among university students.Similar studies have been carried out in Indonesia to determine the relationship between the knowledge of mothers and attitudes toward vitamin A supplementation to their children (22,26,27).However, in this study, we focus on the prevalence of night blindness-related vitamin A deficiency (VAD) due to unhealthy eating attitudes with inadequate vitamin A intake in university students.College students may experience hidden malnutrition for certain essential nutrients, including vitamin A and vitamin E (28).
This study reported that the prevalence of night blindness was five times higher in male than female students.Similar results were also seen in a cross-sectional study by Faruqui et al., who reported that the prevalence of color vision deficiency (CVD) in male medical students was higher than in female medical students (29).The risk of blindness tends to be higher in men due to a mutation in the nyctalopia gene   (NYX) on Xp11.4 and X chromosome-related deficiencies in men (30).Night blindness in male students may also led by screen time.

Respondent characteristic n (%)
The prevalence of night blindness did not differ significantly between the two age groups because the participants were enrolled in the same year of their bachelor's study.However, in children, age was mainly related to the prevalence of night blindness (31).Another study by Shrestha et al. reported that low awareness of common ocular conditions, including night blindness, is associated with factors such as female gender, old age, lower levels of education, and rural habitation.Thus, health literacy promotion can be helpful for eye care services (32).
The participants with a low-middle level of knowledge on vitamin A had two times higher risk of night blindness symptoms.It can also be seen from the result of the association between the cluster of the

No
Respondent characteristic

26
I have limited driving in the rain at night because of difficulty seeing.

27
I limit your driving at night due to my vision.

28
I have difficulty seeing while driving at dawn or dusk because of glare.

29
I worry or I am concerned that I may make a mistake at a social event because I cannot see well enough under poor lighting conditions (for example, getting food on a fork, recognizing people, or reading the menu in a dimly lit restaurant).(23).
Nineteen percent out of 295 students with a high level of knowledge about vitamin A and 8.7% out of 209 students from the medicine cluster of study program showed a symptom of night blindness.We speculate that they could have suffered from night blindness due to stress, heavy workload, and lack of time; university students tend to make poor food choices.Thus, it is challenging for them to adhere to vitamin A-rich food.A student enrolled in the medicine cluster of the study program has a stressful environment due to the extensive curricula, numerous academic requirements, and frequent, complex, and various types of examinations (35).It can also be caused by their long screen time.Dixit et al. reported that screen time was associated with adolescents' increasing prevalence of poor, uncorrected visual acuity (36).
The attitudes toward vitamin A consumption were significantly associated with night blindness (odds ratio = 2.560, 95% CI = 1.215-5.392).However, 21.2% of the 273 students with high attitudes toward vitamin A consumption showed high symptoms of night blindness.This study is consistent with a previous study stating that attitudes did not always translate into practice; for example, although 60.5% agreed on the adverse effect of interruption during mealtime on food intake, they do not interrupt a patient during mealtime (37).Adequate vitamin A supplementation is reported to be an effective treatment of night blindness because vitamin A deficiency tends to be reversible (5).The Food and Nutrition Board, Institute of Medicine-National Academy of Sciences advises that the Recommended Daily Allowance (RDA) for >18 years of age people is 700 mg/d for females and 900 mg/d as retinol activity equivalents (RAE's), while the Tolerable Upper Intake Level (ULs) for males is 3,000 mg/d (38).
This study was subject to several limitations.First, this study was a cross-sectional design; thus, it is difficult to determine whether the low level of knowledge and attitudes of vitamin A preceded the night blindness.Second, data collection by questionnaire may have led to recall bias and misreporting of vitamin A-rich food consumption.Regarding the attitude questionnaires toward vitamin A consumption, no quantitative data on daily vitamin A-rich food portions or vitamin A supplementation was available to identify the association between the practices and night blindness of university students.Furthermore, unfortunately, we do not physically observe the night blindness symptoms or measure the serum retinol level of our respondents.Although this study represents a private university in Semarang, Indonesia, and thus is not representative of all university students, our study was the first to show vitamin A consumption among university students and its association with night blindness in Indonesia.

Conclusion
The results of this study show that the risk of night blindness in university students can be prevented by increasing their knowledge and attitudes toward consuming vitamin A-rich food.Continuous education on the role of a healthy diet is needed to educate undergraduate students, especially those studying in the non-medicine 21 years old 200 (48.8)• 22-25 years old 209 (51.2) The cluster of study program • Medicine 229 (56.0) • Non-medicine 180 (44.0)

20 I
have difficulty seeing under kitchen counters or in cabinets or closets because there is not enough light.21Ihave difficulty with my peripheral vision under poor lighting conditions.22Ihave difficulty with my peripheral vision at night.23 I have difficulty with my peripheral vision in bright sunlight 24 I have difficulty reading street signs when driving at night.25 While driving at night, I have difficulty headlighting from oncoming cars.

TABLE 1
The questions on knowledge regarding vitamin A administered to university students (n = 409).

TABLE 2
The questions on attitudes regarding vitamin A administered to university students (n = 409).

TABLE 3
The questions on symptoms of night blindness using the Low Luminance Questionnaire (LLQ) administered to university students (n = 409).
30I feel bad or depressed about my ability to see at night or under poor lighting conditions.31Ifeelbador depressed because my vision at night or under poor lighting keeps me from doing all that me would like to do.32I feel bad or depressed that I am not able to help others as much as I want because of my vision at night or under poor lighting.

TABLE 5
The relationship between sex, age, a cluster of study program level of knowledge about vitamin A and attitudes toward vitamin A consumption and night blindness symptom.cluster of the study program.To improve this practice, the university can provide health promotion and vitamin A supplementation to prevent night blindness in academia.
*Bivariate analysis of the chi-square test.